Pediatric Dental and Vision under the Affordable Care Act

Starting in 2014, one of the essential health benefits (EHBs) that must be included in medical coverage sold to individuals or small businesses under the Affordable Care Act (ACA) is pediatric dental and vision.

Essential pediatric dental benefits include no plan maximums for in-network services, out-of-pocket maximums that vary per state, and coverage for medically-necessary orthodontia, for children 19 years old and younger.

Small employer groups can elect stand-alone dental benefits with EHB compliant benefits or they can request to renew/modify in force dental benefits meet EHB compliance; however, in some cases the medical insurers will still build-in to the medical plans the EHB pediatric dental as part of their interpretation of, and way of handling their new and current clients, in compliance with the law. Groups are advised to check with us or their insurer first, before making any dental plan decisions or modifications.

Below is a list of how the NJ Small Group insurers are handling EHB compliant pediatric dental benefits starting January 1, 2014:

  • Aetna: embedded in the medical plan; a group cannot waive it
  • Amerihealth: pediatric dental rates will be included in all renewals and must be manually added into rates for new business. Rates are per insured regardless of age.
    In order for the group to waive this coverage they need to supply the following:

    Copy of new policy documents

    Copy of invoice

    Copy of welcome letter for other/new policy

  • Horizon: automatically included with all renewing groups; must be added in to new business quotes. Rates are charged only per child dependent under 19 years of age. Everyone will receive plan booklets and ID cards even if they are not enrolled but will not be charged.
In order for the group to waive this coverage they need to supply a letter on company letterhead stating they have a qualified/compliant EHB dental plan in force (include carrier name, policy #, copy of plan details, and effective dates of coverage) and as such wishes to waive the Horizon ‘Young Grins’ dental program
  • UnitedHealthcare/Oxford:¬†embedded in the medical plan; a group cannot waive it